2024 Camp Healing Hearts Registration

2024 Camp Healing Hearts Registration

Please note: If you are registering more than one child, you may add in the information for each child using one application. Please clearly indicate the information for each child in each section of the form. Please fill out ALL information legibly. A complete registration and registration fee payment is required to register for Camp. Should you have any questions, please call our Camp Director at (315) 634-2141.
First Time Campers:

Spots are limited, so campers are accepted on a first come, first serve basis in order of completed applications received.

Returning Campers:

Camp Healing Hearts wants to give all children a chance to experience its healing power. Due to the limited space, returning campers will be placed on a waiting list, and parents will be notified if there are openings available. Registration fees (checks, money orders, etc.) will not be deposited until this time, and returned, if needed. The waiting list will be managed on a first come, first served basis, therefore, completed applications received sooner will receive a higher spot on the waiting list.

The application is considered completed when the application form is filled out completely, consents signed, and registration fee is received.

If you have any questions regarding the application process, please contact our Camp Director at 315-634-2141.
PLEASE COMPLETE THE ENTIRE CAMPER REGISTRATION BELOW:
Camper's Legal Name:

First NameLast Name
Camper's Preferred Name:
Camper's Date of Birth
Month/Day/Year
Camper's Age (at Camp)
Camper's Gender (Optional):
Camper's Ethnicity/Race (Optional):
Grade for School in September 2022:
Camper's School Name:
Camper's Parent(s)/Guardian(s) Full Legal Name(s):
Address of camper: (Please include address of Parent(s)/Guardian(s) if different)
Contact number(s) and type (home,work, cell)
Allowed to leave a message? If YES, please indicate home, work or cell:
Email address:
Authorized to talk to anyone else besides parent/guardian entered? If yes, provide names of those authorized:
Emergency Contacts and Authorized Pick-Ups (Other than Parent(s)/Guardian(s): (include Full Name, Relationship, and Telephone #)
Camper's T-shirt - Please check size as follows:

CHILD Small (6-8)CHILD Medium (10-12)CHILD Large (14-16)ADULT SmallADULT MediumADULT LargeADULT XLOther
Has this camper previously attended Camp Healing Hearts in person or virtual? (Indicate YES or NO)
Yes or No
How did you hear about Camp Healing Hearts? (referral source)
(Newsletter, Physician, Media, Friend/Family)
Bereavement History:

Please include as many details as possible when answering the following questions. We understand that answering some of these questions might be difficult; however, we want to be able to provide the best possible support for each camper.
Full name of person(s) who died:
Relationship(s) to child:
Birth date and age of person(s) who died:
Date of death(s):
Was the person(s) who died receiving Hospice of CNY and Hospice of the Finger Lakes Services at the time of death?

YesNo
Did this camper receive services at The Hospice Grief Center?

YesNo
If the answer to the above is Yes, when?
What were the cause and circumstances of the person's death(s)?
Was there a funeral or memorial service?

YesNo
If YES, did the camper attend, and what were their comments/reactions to the service(s)? Is there anything the child has not been told about the death(s)?
How would you describe the camper's relationship with the person(s) who died:
How does the camper's family communicate about the death(s) and the person(s) who died?

We talk about it oftenWe talk about it sometimesWe rarely or never talk about itWe avoid talking about it
Comments:
REACTION TO THE DEATH(S): Please explain how camper shows their grief:
Is the camper currently receiving or received any professional support or counseling (i.e. therapist, support group, psychiatrist, or pastoral support)?

YesNo
If Yes, which type of professional support was utilized, and what were/are the circumstances?
Have there been any other changes or stresses in the camper's life (i.e. illness, relocation, divorce, remarriage, finances, other losses)? Please explain.
Please describe the camper's personality/character traits (i.e. easy-going, shy, out-going, takes time to warm up, etc.)
Are there any language, disability, and/or religious needs that we should be aware of to better serve this camper?
Are there any other special needs, family customs, or cultural aspects to the camper's grieving that we should be aware of?
Camper Physical & Health History Form

This form needs to be fully filled out for application to be considered complete.
CAMPER'S NAME:

First NameLast Name
Section I - HEALTH HISTORY

Has camper experienced/experiences ANY of the following:

Please answer YES or NO below:

	YES	N0
Asthma
Autism Spectrum Disorder (ASD)
Diabetes
Seizures
Meningitis
Fainting
Heart Disease
Intellectual Disability
Wears Glasses
Hearing Impairment
Nosebleeds
Sickle Cell Anemia
Constipation/Diarrhea
Attention Deficit Hyperactivity Disorder (ADHD)
Attention Deficit Disorder (ADD)
Serious Illness or Accident
Other

If you answered YES to any above, please explain further:
Section II - ALLERGIES
Are there any allergies to food, medicine, bee stings or other?

YESNO
IF YES, please specify allergy and precautions taken:
Will an EPI Pen be brought to Camp Healing Hearts? (please check one)

YESNO
Section III - MEDICATIONS
Will medication need to be administered at Camp Healing Hearts?

YESNO
If YES, identify medication and directions for administration. Please include the following information: Medication Name, Dosage, and When Taken
If YES, identify medication and directions for administration. Please include the following information: Medication Name, Dosage, and When Taken
Will an Inhaler be brought to Camp Healing Hearts?

YESNO
If YES, will child be responsible for Inhaler or will it be given to the Camp Nurse? Please check ONE:

ChildCamp Nurse
I give the camp staff permission to administer over-the-counter medications available to my child as needed (ie: Tylenol, Ibuprofen, Caladryl, Benadryl, Maalox, etc.)

YESNO
Name of Camper's Physician and Telephone#:
Hospital of Choice:
Camper's Health Insurance & Effective Date:
Camper's Health Insurance Plan Number
Camper's Health Insurance Group Number
To the best of my/our knowledge, the above information is correct and accurate. I/We give permission to agents of Hospice of CNY and of the Finger Lakes' Camp Healing Hearts to administrator first aid to my camper/child and authorize emergency transport to the nearest acute care facility.
SIGNATURE OF PARENT(S)/GUARDIAN(S)/DATE - To request/authorize medication prescribed by our physician to be administered during Camp:

Clear
If bringing Medication, Inhaler, or EPI Pen to Camp Healing Hearts:

I/We authorize and request Hospice of CNY and of the Finger Lakes' Camp Healing Hearts to administer the medication(s) prescribed by our physician, and in so doing relieve the camp, its agents, employees or representatives, of any responsibility for ill effects which may result from administering of said prescribed medication(s) as per the physician's directions listed above.
Signature of Parent(s)/Guardian(s)/Date to confirm information is correct and accurate on form and agree to first aid to be administered in case of emergency:

Clear
Release & Camp Application Checklist

Hospice of CNY and of the Finger Lakes' Camp Healing Hearts Release:
CAMPER'S NAME:

First NameLast Name
List additional Camper(s):
GUARDIAN'S NAME:

First NameLast Name
In consideration of the above-named camper(s) and guardian(s) being granted permission to attend Hospice of CNY and Finger Lakes' Camp Healing Hearts:

I/We agree to indemnify and hold harmless Hospice of CNY and of the Finger Lakes' Camp Healing Hearts for any and all claims, demands, actions and judgments whatsoever of every name and nature, both in law and equity, which my camper/child ever had or now has or may have had against Hospice of CNY and of the Finger Lakes' Camp Healing Hearts for all personal injuries, either physicial or emotional, known or unknown, and injury to property, real or personal, sustained by my camper's/child's person or property duirng their attendance at Hospice of CNY and of the Finger Lakes' Camp Healing Hearts, including but not limited to injury caused by or arising from Hospice of CNY and of the Finger Lakes' Camp Healing Hearts own negligence.

I/We hereby give permission for my camper/child to attend Hospice of CNY and of the Finger Lakes' Camp Healing Hearts on Friday, August 2nd. I understand that the camp's goal is to help facilitate the bereavement process of my child and provide support for them in expressing feelings of grief.

I/We give permission for the camper (my child) to be photographed, videotaped or interviewed during Hospice of CNY and of the Finger Lakes' Camp Healing Hearts under staff supervision. This material may be used for future publicity of Hospice of CNY and of the Finger Lakes' Camp Healing Hearts, including the news media.

I/We, the undersigned, have read this release and understand all of its items.
SIGNATURE OF PARENT(S)/GUARDIAN(S)/DATE - to confirm we understand all items and have read this release:

Clear
Registration Fee Payment

Individual Camper -$25

Family - $50
Please select payment type:*

CHECK/MONEY ORDER: Please make your check/money order payable to: Hospice of CNY and of the Finger Lakes and mail with your completed application to: 990 7th North Street, Liverpool, NY 13088CREDIT/DEBIT CARD: To make a payment with your credit/debit card, please call 315-634-1100 or go to our website at https://www.hospicecny.org/camp-healing-hearts-2024/ and click on the link to make an online payment.
*Registration must be received by July 12th to be considered*

Please call the Camp Director with any questions about the application process at 315-634-2141.

DON'T FORGET TO CLICK SUBMIT BELOW WHEN FINISHED!
Should be Empty:

2024 Camp Healing Hearts Registration

PLEASE COMPLETE THE ENTIRE CAMPER REGISTRATION BELOW:

Bereavement History:

Camper Physical & Health History Form

Release & Camp Application Checklist

Registration Fee Payment

Individual Camper -$25

Family - $50

*Registration must be received by July 12th to be considered*

Please call the Camp Director with any questions about the application process at 315-634-2141.

DON'T FORGET TO CLICK SUBMIT BELOW WHEN FINISHED!

Registration must be received by July 12th to be considered